Professional Abstract

Objective

To compare the effectiveness of prescription medicine, nonspecific group exercise classes, and chiropractic and physical therapy combined with rehabilitative exercises for reducing pain and increasing walking ability in patients with lumbar spinal stenosis (LSS)

Study Design

Design Elements	Description
Design	Randomized controlled trial
Population	259 adults ages 60 and older who had difficulty walking due to LSS
Interventions/ Comparators	Prescription pain and antidepressant medicines; epidural steroid injections for nonresponders Community-based group exercise classes Clinic-based chiropractic and physical therapy combined with rehabilitative exercises designed to treat LSS
Outcomes	Primary: self-reported level of pain and physical function, test of walking ability Secondary: daily physical activity
Timeframe	6-month follow-up for primary outcomes

The research team compared three nonsurgical treatments for LSS to see if the treatments reduced pain and increased walking ability in patients with LSS.

To be eligible for the trial, participants had to be able to walk at least 50 feet without assistive devices and able to engage in light exercise, like back stretches or riding a stationary bike for 5 to 10 minutes. In this study, 77% of patients were white, 22% were black, and 1% were other races. The average patient age was 72, and about half of patients had a college degree. The study took place in Pittsburgh, Pennsylvania.

The research team randomized patients to one of three groups. Patients in the first group received prescription medicine as needed, including pain medication and antidepressants. For progressive pain, patients received epidural steroid injections. Patients in this group met with a physician three times. The physician reviewed the patients’ current medicines for LSS and modified the medicine regimen as needed for pain. In the second group, patients attended two group exercise classes per week led by fitness instructors at a local senior community center. Exercises were for general fitness. Two times each week, patients in the third group had chiropractic and physical therapy combined with rehabilitative exercises designed to treat LSS. The interventions in each group lasted for six weeks.

Patients with LSS, community senior centers directors, and doctors gave input on the study design to the research team.

Results

• All three groups showed improvement in mean scores for pain and physical function at two months. Participants who received chiropractic and physical therapy had a significantly greater improvement compared with those who did group exercise (-2.4 points; 95% confidence interval [CI], -4.2, -0.6) or received prescription medicine (-2.1 points; 95% CI, -3.9, -0.4). Patients in all three groups showed the same level of improvement in walking ability.
• At six months, there were no significant differences between groups in improvement in pain and physical-function scores. Although all three groups showed improvement in walking ability, there were no statistically significant differences between the three groups.
• Compared to those who received prescription medicine, patients who took group exercise classes had statistically significantly greater improvement in daily physical activity after two months. However, compared to baseline, none of the groups showed improvement in physical activity after six months.

Limitations

Some patients took off the armband used to measure daily activity because it was uncomfortable, resulting in missing data at follow-up. Daily activity results may have been different if all patients had used the armband. The walking test only assessed patient ability to walk on flat surfaces; results may not be generalizable to more challenging mobility tasks.

Conclusions and Relevance

In the short term, chiropractic and physical therapy patients had the greatest improvements in pain compared with patients in the exercise and prescription medicine groups. At six months, all three groups showed similar improvements in pain, physical function, and walking ability. For patients who choose not to have surgery, all three interventions may improve their ability to manage their LSS.

Future Research Needs

Further research could examine the effectiveness of using these treatments for longer periods or test different combinations of these interventions.